*** Note that the map above still shows Maine as a non-expansion state. Maine voters have approved Medicaid expansion (it was supposed to take effect in July 2018) but the outgoing Governor has resisted the expansion process and there is an ongoing legal battle over the implementation of Medicaid expansion in Maine. It’s expected to be resolved in January 2019, when Governor-elect Janet Mills takes office and moves forward with Medicaid expansion implementation. In addition, Virginia is shaded as a Medicaid expansion state, although expanded coverage won’t take effect there until January 2019 (but enrollment began in November 2018). Utah, Nebraska, and Idaho will all expand Medicaid in the near future under the terms of ballot initiatives that were passed in those states in the 2018 election***
State changes ahead for Medicaid
- Since 2010, 32 states have accepted federal funding to expand Medicaid under the ACA, and at least four more are expected to do so in 2019.
- Maine approved a ballot initiative in 2017 to expand Medicaid. Utah, Idaho, and Nebraska approved expansion initiatives on their 2018 ballots.
- In 2018, Virginia lawmakers approved Medicaid expansion, which takes effect in January 2019 (enrollment began in November 2018).
- Five states have received federal approval for Medicaid work requirements. Several others have pending waivers or are considering submitting waivers.
- Some states are attempting to change Medicaid by implementing lifetime caps on coverage, or by adjusting eligibility requirements.
- A handful of states have been exploring Medicaid buy-in programs.
- Fourteen states have yet to take ACA’s Medicaid expansion. It was 19 as of mid-2018, but Maine, Virginia, Utah, Idaho, and Nebraska are joining the list of expansion states.
- New Hampshire, Indiana, Pennsylvania, Alaska, Montana, and Louisiana have expanded their Medicaid programs since 2014. Virginia is expanding Medicaid as of January 2019. Maine is expected to do so in early 2019. And Utah, Nebraska, and Idaho are also expected to expand coverage in 2019.
- The 14 states that haven’t expanded coverage are missing out on $305 billion in federal funding if they continue to reject expansion.
- Public support for Medicaid expansion is strong, with 56 percent of the public in favor of expansion even in deep-red Wyoming.
When the Affordable Care Act was enacted in 2010, Medicaid expansion was a cornerstone of lawmakers’ efforts to expand realistic access to healthcare to as many people as possible. The idea was that everyone with household incomes up to 133 percent of poverty (138 percent with the 5 percent income disregard) would be able to enroll in Medicaid.
Since 2010, the number of states that have accepted ACA’s Medicaid expansion has steadily grown – from just a handful by 2012 to 36 states as of November 2018. but that number includes several states that don’t actually have people enrolled in expanded Medicaid in 2018. Maine voters approved expansion that was to take effect in July 2018, but Gov. Paul LePage has yet to more forward with implementation, and the issue has triggered a legal battle in the state that likely won’t be resolved until Governor-elect Janet Mills takes office; Virginia Medicaid expansion takes effect in January 2019; Utah, Idaho, and Nebraska have all passed ballot initiatives to expand Medicaid, with coverage that will take effect in 2019.
At the same time, there are a host of other Medicaid-related developments in the works across the country – both in expansion and non-expansion states – that promise to dramatically affect eligibility for and access to Medicaid benefits. Some states are moving toward changes that would put increased limits on Medicaid eligibility – such as work requirements and lifetime caps – while other states are considering legislation that would give currently ineligible residents a chance to buy-in.
Suffice it to say, there’s plenty of activity to monitor at the state level.
States to watch for Medicaid changes
Several states are considering various changes to their Medicaid systems in 2018. In some cases, lawmakers are considering expansion or directing the state to seek a federal waiver to change the way Medicaid eligibility is handled, and in other states, voters are seeking to expand Medicaid with a ballot initiative:
Medicaid expansion with a ballot initiative
Maine voters approved a ballot initiative in the 2017 election, calling for Medicaid expansion in Maine by July 2018. Governor Paul LePage has refused to move forward with implementation, so the process has been delayed. But the ballot initiative is binding in Maine, so expansion will happen, it’s just a matter of when. More than likely, it won’t happen until Governor-elect Janet Mills takes office. Mills has been serving as the state’s Attorney General, and has been vocal in her support for Medicaid expansion.
Medicaid expansion was on the ballots in three other states in 2018, and Montana voters were given the chance to decide whether to continue Medicaid expansion in the state and fund it with an additional tax on tobacco products:
- Utah: Medicaid expansion passed, by a vote of 54 to 46. Under the terms of the ballot initiative, Medicaid is to be expanded by April 1, 2019.
- Idaho: Medicaid expansion passed, by a vote of 60 to 40. Under the terms of the ballot initiative, Idaho has to submit a state plan amendment to CMS within 90 days.
- Nebraska: Medicaid expansion passed, by a vote of 53 to 47. Under the terms of the ballot initiative, Nebraska has to submit a state plan amendment to CMS by April 1, 2019.
- Montana: Medicaid is already expanded in Montana, but that will end in June 2019 unless it’s reauthorized. The ballot initiative was to generate funding, via a tobacco tax, to help pay for the state’s share of the cost of ongoing expansion, and to provide for ongoing Medicaid expansion that doesn’t have to be reauthorized. The measure failed, however, by a vote of 53 to 47. That means Montana lawmakers will have to reauthorize Medicaid expansion during the 2019 legislative session, or else Medicaid expansion will end in Montana as of July 2019.
Legislation to expand Medicaid
Lawmakers in the states that haven’t expanded Medicaid have continued to introduce legislation each year in an effort to expand coverage. In 2018, Virginia lawmakers have passed a budget that includes Medicaid expansion, with coverage effective January 2019 (enrollment began in November 2018). The measure will eventually include a work requirement and premiums/cost-sharing for enrollees with income above the poverty level, but it’s expected to make coverage newly-available to 400,000 Virginia residents.
Medicaid work requirements
Requiring people to be working (or volunteering, in school, in job training, etc.) for at least a certain number of hours per week is an idea that tends to be popular with Republican lawmakers. Most people who receive Medicaid benefits are either already working or would be exempt from work requirements (due to being disabled, taking care of a minor child, pregnant, etc.), but the myth of the “welfare queen” (or king) persists, and Medicaid work requirements are seen by some as a solution to a perceived problem.
The federal Centers for Medicare and Medicaid Services (CMS) has to approve a Medicaid work requirement before a state can implement it. The Obama Administration did not allow any work requirements for Medicaid, but the Trump Administration is much more open to the idea. As of November 2018, five states had received federal approval for work requirements. Several others have pending waivers or are expected to submit waivers in the near future. You can click on the link for each state to learn more about the approved or proposed work requirements.
Work requirements for states that have expanded Medicaid:
- Arkansas (approved, effective June 2018 for people age 30-49; people age 19-29 will have to comply as of 2019) — 80 hours per month
- Indiana (approved, phased in, starting in 2019) — 5 hours per week initially, increasing to 20 hours per week
- New Hampshire (approved, effective January 2019) — 100 hours per month
- Kentucky (approved, was to be effective July 2018, but a federal judge halted the implementation of the work requirement in late June; CMS reopened the comment period and ultimately reapproved the work requirement, with no substantial changes, with an April 2019 effective date) — 80 hours per month
- Arizona (pending CMS approval) — 20 hours per week
- Ohio (pending CMS approval) — 20 hours per week
- Michigan (pending CMS approval) — 80 hours per month (Michigan legislation initially called for 29 hours per week of work/community engagement, but it was revised to 80 hours per month before the final bill passed). In the 2018 election, while the work requirement waiver was pending federal approval, Michigan voters elected Democrat Gretchen Whitmer to be the state’s next governor. The details of the work requirement are in state law, so it’s unclear how much leeway Whitmer will have to avert or modify the proposed work requirement. But her administration is likely to push back on at least some aspects of it.
- Virginia enacted a budget that calls for Medicaid expansion starting in January 2019, but also directs the state to seek federal permission for a work requirement. The work requirement would phase in, starting with 20 hours per month after a person has been enrolled for three months, and ramping up to 80 hours per month by the time the person has been enrolled for a year. The work requirement is also likely to be delayed up to two years after expansion takes effect.
Lawmakers in Louisiana considered several work requirement bills in 2018, but none were enacted. Lawmakers in Pennsylvania passed Medicaid work requirement legislation in 2017 and again in 2018, but Governor Tom Wolf vetoed both bills.
Work requirements for states that have not expanded Medicaid:
Several states that have not expanded Medicaid are seeking federal permission to impose Medicaid work requirements, despite the fact that their Medicaid populations are comprised almost entirely of those who are disabled, elderly, or pregnant, as well as children.
The Trump Administration has yet to grant work requirements in any of these states, and in May 2018, CMS Administrator, Seema Verma clarified that these states will have to clearly demonstrate how they plan to avoid situations in which people lose access to Medicaid as a result of the work requirement, and yet also do not have access to premium subsidies in the exchange. For the time being, the following non-expansion states are seeking federal permission to impose a Medicaid work requirement:
- Wisconsin (approved; fulfilling the work requirement would be necessary to avoid the proposed 48-month cap on Medicaid benefits) — 80 hours per month. A week after CMS approved Wisconsin’s waiver, voters elected Democrat Tony Evers to be the state’s next governor, replacing Republican Scott Walker. Evers is opposed to the work requirement, but it’s unclear how much latitude his administration will have to adjust the waiver that CMS has approved.
- Maine (pending CMS approval) — 20 hours per week. Medicaid expansion has been approved by voters in Maine, but not yet enacted
- Mississippi (pending CMS approval) — 20 hours per week
- South Dakota (pending CMS approval) — 80 hours per month
- North Carolina (pending CMS approval, but lawmakers would have to first approve the Carolina Cares legislation, which calls for expanded Medicaid with a work requirement; North Carolina has not proposed a work requirement for the currently-eligible Medicaid population)
- Kansas (pending CMS approval) — 20 or 30 hours per week, depending on circumstances
- Utah (pending CMS approval for Primary Care Network population; proposed for modified expansion) 20 or 30 hours per week, depending on circumstances (aligned with TANF rules).
- Alabama (pending CMS approval) — 35 hours per week
- Tennessee (legislature passed a bill that directs the state to seek approval for a work requirement, using TANF or other federal funds to implement the work requirement) — number of hours is not specified in the legislation, but is likely to be set at 20 hours per week.
- Oklahoma (legislation enacted in 2018, and executive order signed in 2018, direct the state to seek federal approval for a Medicaid work requirement. Waiver proposal has been drafte but had not been submitted to CMS as of early November).
Other Medicaid proposals to watch
Five states are seeking CMS approval to implement lifetime caps for Medicaid coverage: Arizona, Kansas, Maine, Utah, and Wisconsin. Thus far, CMS has not approved this provision for any states, and has notified Kansas that the proposal for a lifetime Medicaid cap will be rejected.
The Trump Administration also rejected Arkansas’ proposal to cap Medicaid eligibility at 100 percent of the poverty level, instead of 138 percent. Massachusetts has a similar request pending CMS approval, and Utah enacted legislation in 2018 directing the state to seek approval to expand Medicaid only to those earning up to the poverty level.
And no states have received approval for an asset test for Medicaid, although some, including Maine, are seeking such approval.
Several states have received approval, however, to impose premiums on certain Medicaid populations, restrict retroactive eligibility, and require more eligibility redeterminations.
New Hampshire enacted legislation in 2018 that directs the state to drop the current private approach to Medicaid expansion (buying policies in the exchange for people eligible for expanded Medicaid) and switch to a Medicaid managed care program instead. The state submitted a waiver amendment proposal to CMS in August 2018, seeking permission to implement the changes.
Some states have also considered the possibility of seeking approval for a Medicaid buy-in program, under which people who aren’t eligible for Medicaid would be allowed to purchase Medicaid coverage. Nevada lawmakers passed legislation to do so in 2017, but the governor vetoed it. Lawmakers in Colorado, Maryland, and New Mexico considered legislation in 2018 that would direct the state to conduct a study on the feasibility and cost of a Medicaid buy-in program (ie, allowing people who aren’t eligible for Medicaid to purchase Medicaid coverage instead of private market coverage). Colorado lawmakers ultimately did not pass the bill, and neither did Maryland lawmakers. But New Mexico enacted legislation in early 2018 calling for a study on the costs and ramifications of a Medicaid buy-in program.
Minnesota lawmakers considered, but did not pass, a bill in 2017 that would have allowed people to buy into MinnesotaCare, the state’s Basic Health Program (similar to Medicaid, but for people with slightly higher income). This issue is being revisited in 2018, however, and Minnesota Governor Mark Dayton supports it. Thus far, Medicaid buy-in has not gained much traction. But Democrats have been warming to the idea of a public option or single payer system, and Medicaid buy-in would certainly be a step in that direction.
History of Medicaid expansion
As noted at the start of this summary, Medicaid was a cornerstone of ACA lawmakers’ efforts to expand access to healthcare. The idea was that everyone with household incomes up to 133 percent of the federal poverty level (FPL) would be able to enroll in Medicaid.
People above that threshold – but whose incomes didn’t exceed 400 percent of FPL – would be eligible for premium tax credits in the exchanges to make their coverage affordable. And although there are some exceptions, most people in the individual health insurance market with incomes above 400 percent of poverty are able to afford insurance even though they don’t qualify for subsidies.
(Regardless of income, people who get their insurance from an employer receive subsidies in the form of the employer’s contribution to their premiums – and their premiums are pre-tax).
Because Medicaid expansion was expected to be a given in every state, the law was written so that premium subsidies in the exchange are not available to people with incomes below the poverty level. They were supposed to have access to Medicaid instead.
14 states still say ‘No’ to Medicaid expansion (it was 19, but Maine, Virginia, Utah, Idaho, and Nebraska are expanding in 2019)
Unfortunately for millions of uninsured Americans, in 2012 the Supreme Court ruled that states could not be penalized for opting out of Medicaid expansion. And 14 states have not yet expanded their programs. (Until late 2015, there were still 22 states that had not expanded Medicaid, but Montana began enrolling people in their newly expanded Medicaid program in November 2015, for coverage effective January 2016, Alaska‘s Medicaid expansion took effect in September 2015, Louisiana‘s Medicaid expansion took effect in July 2016, and Virginia began enrolling people in expanded Medicaid as of November 2018, for coverage effective January 2019. Maine is expected to expand Medicaid soon after Governor-elect Mills takes office, and Utah, Idaho, and Nebraska are expected to expand Medicaid in 2019, under the terms of the ballot initiatives that passed in each state in November 2018).
Maine is expected to expand Medicaid under the terms of the ballot initiative that voters passed in November 2017, but the governor’s resistance has delayed the process. Originally, it was slated to take effect in July 2018, but a legal battle over the governor’s refusal to move forward with expansion is ongoing as of November 2018, and the issue may not be resolved until Governor-elect Mills takes office in January 2019 (Maine’s Governor submitted a court-ordered Medicaid expansion proposal to CMS in September 2018, but urged CMS to reject the proposal due to a lack of funding; Governor-elect Mills will instead urge CMS to accept the state’s Medicaid expansion proposal, and will drop the LePage Administration’s legal battle against expansion).
So as of November 2018, expanded Medicaid is not available in 19 states, including Maine, Virginia, Utah, Nebraska, and Idaho. But expanded coverage is available in Virginia as of January 1, 2019 (enrollment began in November 2018), and is expected to be available in the other four states at some point in 2019.
As a result of the failure to expand coverage in the other 14 states, the Kaiser Family Foundation estimates there are 2.1 million people in the coverage gap across 13 of those states (although Wisconsin has not expanded Medicaid under the ACA, BadgerCare Medicaid is available for residents with incomes up to the poverty level, so there is no coverage gap in Wisconsin). The Kaiser Family Foundation analysis no longer includes Maine, because expansion was supposed to take effect there as of July 2018. In reality, there are likely at least 25,000 additional people in the coveage gap, due to the continued lack of Medicaid expansion in Maine, but that’s expected to change in early 2019. And although Utah, Nebraska, and Idaho are still listed on the Kaiser Family Foundation analysis, they are all expected to expand coverage in 2019, and their combined total number of residents in the coverage gap is only 84,000 people.
Being in the coverage gap means you have no realistic access to health insurance. These are people with incomes below the poverty level, so they are not eligible for subsidies in the exchange. But they are also not eligible for their state’s Medicaid program.
In many of the states that have not expanded Medicaid, low-income adults without dependent children are ineligible for Medicaid, regardless of how little they earn. For those who do have dependent children, the income limit for eligibility can be very low: In Alabama, parents with dependent children are only eligible for Medicaid if their income doesn’t exceed 18percent of the poverty level. For a family of three, that’s only $312 per month (and yet, Alabama wants to impose a work requirement on those parents who are currently eligible for coverage).
Although the 2.1 million people in the coverage gap can qualify for an exemption from the shared responsibility provision — and are thus not subject to the ACA’s penalty for not maintaining health insurance — that’s likely to be little consolation to those who want and need health insurance but are unable to obtain it because their state has rejected Medicaid expansion (the penalty for not having coverage is still in effect as of 2018; it will be repealed after the end of 2018, under the terms of the GOP tax bill that was enacted in late 2017).
More states easing into expansion
New Hampshire, Indiana, Pennsylvania, Alaska, Montana, and Louisiana all expanded their Medicaid programs since mid-2014. And Virginia lawmakers passed Medicaid expansion in a special legislative session in May 2018, albeit with a work requirement. Virginia’s Medicaid expansion takes effect in January 2019, and enrollment began in November 2018.
The 2018 election was pivotal for Medicaid, with three states passing ballot initiatives to expand Medicaid, and Kansas, Wisconsin, and Maine electing governors who are supportive of Medicaid expansion.
The first six states to implement Medicaid did so in 1966, although several states waited a full four years to do so. And Alaska and Arizona didn’t enact Medicaid until 1972 and 1982, respectively. Eventually, Medicaid was available in every state, but it certainly didn’t happen everywhere in the first year.
There’s big money involved in the Medicaid expansion decision for states. Under ACA rules, the federal government pays the vast majority of the cost of covering people who are newly eligible for Medicaid. Through the end of 2016, the federal government fully funded Medicaid expansion. The states started to pay a small fraction of the cost starting in 2017, eventually paying 10 percent by 2020. From there, the 90/10 split is permanent; the federal government will always pay 90 percent of the cost of covering the newly eligible population, assuming the ACA remains in place.
The cost of NOT expanding Medicaid eligibility
Because the federal government funds nearly all of the cost of Medicaid expansion, the 14 states that haven’t yet taken action to expand Medicaid are missing out on more than $305 billion in federal funding between 2013 and 2022, if they continue to reject Medicaid expansion. (Indiana, Pennsylvania, Alaska, Montana, Louisiana, and Virginia have expanded their Medicaid programs since that report was produced in 2014, so they are no longer missing out on federal Medicaid expansion funding. Maine, Virginia, Utah, Nebraska, and Idaho are expected to expand Medicaid in 2019, and will begin receiving federal Medicaid expansion funding at that point, so they’re also not included in the $305 billion total)
Just five states – Florida, Texas, North Carolina, Georgia, and Tennessee – would have received nearly 60 percent of that funding (a total of $227.5 billion) if they had expanded Medicaid to cover their poorest residents starting in 2013. The good news is that although the federal government is no longer funding the full cost to expand Medicaid, they’ll always pay at least 90 percent of the cost, making Medicaid expansion a good deal for states regardless of when they implement it (in other words, for every dollar a state spends to cover its Medicaid expansion population, the federal government will kick in $9).
For residents of states that haven’t expanded Medicaid, their federal tax dollars are being used to pay for Medicaid expansion in other states, while none of the Medicaid expansion funds are coming back to their own states. From 2013 to 2022, $152 billion in federal taxes will be collected from residents in states not expanding Medicaid, and will be used to fund Medicaid expansion in other states.
Hospitals in states that don’t expand Medicaid are suffering too. Hospitals that treat large numbers of uninsured patients rely on federal funding from Disproportionate Share Hospital (DSH) payments to help cover the cost of the uncompensated care they provide. But DSH payments are being phased out by 2020, because Medicaid expansion was expected to sharply reduce the amount of uncompensated care hospitals must provide. Hospitals in states that have rejected Medicaid expansion will continue to provide a significant amount of uncompensated care, but their funding will be stretched even thinner than it already is.
The human toll of the Medicaid coverage gap
Of course, there’s more to Medicaid expansion than just money. Harold Pollack very clearly explains the human toll of the Medicaid coverage gap: Based on the 3,846,000 people who were expected to be in the coverage gap in January 2015, we can expect 4,633 of them to die in any given year because they don’t have health insurance. (Pollack’s number is higher, because his article was written in May 2014, before New Hampshire and Pennsylvania agreed to expand coverage; Indiana and Alaska also expanded coverage in 2015, and Montana‘s enrollment in Medicaid expansion began in November 2015, for coverage effective January 2016; Louisiana‘s Medicaid expansion took effect in 2016, and Virginia‘s in January 2019. There has been a slow but steady increase in the number of states that have expanded Medicaid).
There has been a slow push towards Medicaid expansion based on those financial and moral arguments, even in some of the reddest states. And the Supreme Court’s June 2015 ruling in King v. Burwell — which upheld the legality of premium subsidies in states that use the federally run health insurance exchange (Healthcare.gov) — gave new life to Medicaid expansion discussions in states that wanted to utilize Medicaid funds to purchase private health insurance for low-income residents (if the Court had struck down subsidies in states that haven’t created their own exchanges, the private insurance market would likely have destabilized and premiums would have skyrocketed).
Public support for Medicaid expansion
Public support for Medicaid expansion is relatively strong, even in Conservative-leaning states: In Wyoming (considered the most Conservative state), 56 percent of the public are in favor of Medicaid expansion. But the Republican-led legislature in Wyoming has consistently rejected Medicaid expansion, despite Republican Governor Matt Mead’s support for expansion.
In Utah, 88 percent of the state’s residents supported Governor Herbert’s 2014 proposal for Medicaid expansion over the status quo, and public support for providing coverage for people in the Medicaid coverage gap has continued to be strong in Utah. Voters in the state approved a ballot initiative in the 2018 election to expand Medicaid, bypassing the legislature and governor altogether. The same thing happened in Nebraska and Idaho in the 2018 election.
In Texas – home to more than a quarter of those in the coverage gap nationwide – a board of 15 medical professionals appointed by Governor Rick Perry recommended in November 2014 that the state accept federal funding to expand Medicaid, noting that the current uninsured rate in Texas is “unacceptable.” (U.S. census data indicated that 16.6 percent of Texas residents were uninsured in 2016 – the highest rate in the country.) But no real progress towards Medicaid expansion has been made since then.
There are several other states where the legislature or the governor – or both – are generally opposed to the ACA, but where Medicaid expansion has been actively considered, either by the governor or legislature or in negotiations with the federal government. These include Kansas, North Carolina, Tennessee, and Missouri, but thus far, none of those states have enacted legislation to expand Medicaid. Kansas lawmakers passed a Medicaid expansion bill in 2017, although then-Governor Sam Brownback vetoed it. But Kansas has elected a Democrat, Laura Kelly, to serve as the state’s next governor. If another Medicaid expansion bill passes in Kansas during her tenure, she can be expected to sign it into law.
Our Medicaid section provides updated state-by-state information on the current status of Medicaid expansion, along with general information about each state’s program. If you’re curious about what’s going on in your state, check it out.
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.